PIERCING CONSENT

PIERCING - INFORMED CONSENT
The following information is designed to help you make an informed decision about getting a new piercing. It is in no way meant to scare, deter, or encourage your decision. I have been given full opportunity to ask any and all questions about the obtaining of a piercing/stretching enlargement from True Blue Tattoo, LLC and that all of my questions have been answered to my full and total satisfaction. As of June 1, 2000 The Texas Department of Health has regulated body piercing in Texas. True Blue Tattoo, LLC adheres strictly to all regulations of The Texas Department of Health.
Choose Piercer*
I specifically acknowledge that I have been advised of the facts and matter set forth below and I agree as follows:

(Please initial on each line next to the letters A-F)
[A]. I acknowledge that I have truthfully represented to the employees, or agents of TRUE BLUE TATTOO, LLC that I am 18 years of age or older. If I have shown false identification, I take full responsibility for my actions and forever release all employees, agents, and representatives of TRUE BLUE TATTOO, LLC Please note, MINORS using fake I.D. will be PROSECUTED. Initial below:*
[B]. I acknowledge that the obtaining of my piercing is by my choice alone. I am not under the influence of drugs or alcohol. I am in good health and have no medical conditions which might cause problems. I also consent to the application of the piercing, and to any actions or conduct of employees, agents and representatives of True Blue Tattoo, LLC, reasonably necessary to perform the piercing procedure. Initial below:*
[C]. I acknowledge that short term health concerns include, but are not limited to the following; potential for topical infection, intolerance and/or reaction to certain metals, tissue rejection of the piercing (especially with minors under 18), nerve damage, pain, scarring, and/or failure of tissue to completely close upon removal of jewelry. Initial below:*
[D]. I acknowledge receipt of written aftercare instructions advising me of the proper care of my piercing. To ensure proper healing of my piercing(s), I agree to follow the procedures outlined in the separate form for the care of my new piercing until the healing is complete. I understand this type of piercing can take up to 2-6 months or longer to heal. Initial below.*
[G]. I understand that all implements used for my piercing will be sterilized prior to the procedure in a Statim Autoclave. All needles are single use only. An indicator strip that tracks the sterilization process will be placed in the statim with the implements. The strip has a clear line that will turn black upon processing.The piercer will show this to me. Initial below.*
Please Answer the following questions...
Are you currently under the care of a physician for any reason?*

YESNO
If Yes, please explain...
Are you currently taking any medication?*

YESNO
If Yes, please explain...
Do you have a history of allergies to anything? *

YESNO
If Yes, please explain...
Have you had any alcohol or medication in the last 24 hours?*

YESNO
If Yes, please explain...
Do you have a history of Low Blood Sugar?*

YESNO
If Yes, please explain...
Do you have a history of Bleeding Disorder?*

YESNO
If Yes, please explain...
Have you had anything to eat in the last 8 hours?*

YESNO
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
I.D. #, Passport #, State License #*
Signature*

Clear
Take Photo of ID*
Date of Birth*

MonthDayYear
Age*
Current Date*

MonthDayYear
Date
Please verify that you are human*
The area below is for the piercer only.
Type of Piercing*
Jewelry*
Validate Customer ID #*
Validate Customer Date of Birth*

MonthDayYear
Piercer Name*

First NameLast Name
Piercer Signature*
Should be Empty:

PIERCING - INFORMED CONSENT